FIS 0507 (10/06) Office of Financial and Insurance Services RENEWAL APPLICATION FOR DEBT MANAGEMENT LICENSE Renewal Application for Debt Management License Attachments and Instructions DUE DATE: December 1st General Instructions: PLEASE NOTE - INCOMPLETE RENEWAL APPLICATIONS MAY BE RETURNED UNPROCESSED 1. Complete the subsequent renewal application (FIS 0507) and attachments. In addition, the following items are required to be filed along with the application. 2. Bond Requirement: Please submit ONE of the following: FIS 0508 Debt Management Surety Bond for Licensee or FIS 0509 Debt Management Deposit of Cash or Securities in Lieu of Bond (Bond must be effective from January 1st to December 31st for the renewal period at issue) 3. If Firm’s Trust Account is to be maintained by a financial institution outside of Michigan, FIS 0517 Alternative Bond in Lieu of Michigan Based Trust Account MUST also be completed. 4. Amendments to firm’s Articles of Incorporation, Articles of Organization or Partnership Agreement, which occurred during the previous 12 months. 5. Current fee schedule used for Michigan clients. 6. A statement that the firm’s budget analysis, debt management contract and creditor agreement forms and any other forms used for Michigan clients are in compliance with the Act and have not changed from the previous year. If any forms have changed, submit amended forms with changes highlighted. 7. Current balance sheet with income statement that is not more than 45 days old when received. 8. Latest audited financial statement only if your firm has 100 or more clients. 9. Personal balance sheet only if you are a sole proprietor. 10. Cashier’s check, money order or company check made payable to the State of Michigan in the amount of $50.00 for each branch office. Fees are non-transferable and non-refundable. Questions pertaining to the completion of this Renewal Application may be directed to the Debt Management Licensing Section at 1-877-999-6442. SEND COMPLETED RENEWAL APPLICATION AND FEES TO: Via Regular Mail Office of Financial and Insurance Services Securities Section P.O. Box 30701 Lansing, MI 48909 Via Overnight Delivery Office of Financial and Insurance Services Securities Section 611 West Ottawa Street, 3rd Floor Lansing, MI 48933 American LegalNet, Inc. www.FormsWorkflow.com FIS 0507 (10/06) Office of Financial and Insurance Services RENEWAL APPLICATION FOR DEBT MANAGEMENT LICENSE This form is required pursuant to the Debt Management Act, P.A. 148, of 1975, as amended. Firm’s Name Firm’s Fiscal Year End Firm’s Home Office Address Firm’s Web Address City State Contact Person Title ZIP Code E-Mail Address ADDITIONAL OFFICES (Attach additional page(s), if necessary) ADDRESS PHONE NUMBER ( ) ( ) ( ) ( MANAGER ) ( Telephone Number ( ) Fax Number ( ) ) Type of Business Entity (check one only): Sole Proprietorship. Give name and home address. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Partnership. Attach list of partners, showing names, home addresses, and whether general or limited partner. Corporation. Attach a list of officers, members and directors, showing names, home addresses, position held and percentage of interest held directly or otherwise. Limited Liability Company or Unincorporated Association. Attach a list of members, giving names, home addresses, positions held and percentage of interest held directly or otherwise. 2 American LegalNet, Inc. www.FormsWorkflow.com Indicate whether the firm, its general partners, members or managers or any of the officers or directors: (Note: This question does not apply to directors or their equivalent if he or she does not receive a salary, stock dividend, or other financial benefit from the corporation or equivalent entity, other than reimbursement of the actual expenses incurred in carrying out the duties of a director of that corporation or equivalent entity.) YES NO 1. Has been convicted of a crime involving moral turpitude which includes forgery, embezzlement, obtaining money under false pretenses, larceny, extortion, conspiracy to default or any other like offenses. YES NO 2. Has been the subject of an order by the Office of Financial and Insurance Services for violating or failing to comply with a provision of the Act, Rules, or an Order promulgated or issued under the Act. YES NO 3. Has had a license to engage in the business of debt management revoked or suspended for any reason other than failure to pay the licensing fees in this state or in another state. YES NO 4. Has ever defaulted in the payment of money collected for others including the discharge of debts through bankruptcy proceedings. YES NO 5. Is associated with any other debt management business entity. If yes, please give the name and address of the business on Schedule A. YES NO 6. Is operating a collection agency or affiliated with one. If yes, please give the name and address of the agency on Schedule A. YES NO 7. Is not at least 18 years of age and a citizen of the United States. YES NO 8. Is a partnership, corporation, limited liability company or association which has not been granted a certificate of authority to do business in this state. YES NO 9. Is engaged in any other business professions besides debt management. If yes, state nature and locations on Schedule A. If you have answered “yes” to any of the above, please attach complete details. The undersigned, _____________________________________, being first duly sworn, deposes and says: That I have executed the following renewal application for and on behalf of the firm named therein; that I am __________________________________ (Officer, Partner, Member or Sole Proprietor) of such firm and fully authorized to execute and file such application; that I am familiar with such application; and that to the best of my knowledge, information and belief the statements made in such application are true and the documents submitted therewith are true copies of the originals thereof. It is fully understood by me that any misrepresentation or false statements or fraud in or in connection with this renewal application shall be cause for revocation of the license issued thereon, in addition to any other action and/or penalty to which I may be subject. Date: __________________________ ____________________________________________ (Name of Firm) By: ___________________________________________ (Name and Title) 3 American LegalNet, Inc. www.FormsWorkflow.com